The lawsuit was filed June 28, 2002, on behalf of Dr. Patrick F. McSharry of Tennessee in Hamilton County Circuit Court. It alleges that "although [UnumProvident] employed various medical doctors for the ostensible purpose of providing needed medical guidance in reaching benefit decisions, the medical personnel were not truly utilized for that purpose. It was [UnumProvident's] primary purpose and policy to deny disability claims."

According to the lawsuit, although UnumProvident hired McSharry and other doctors to provide the necessary medical guidance to reach benefit decisions, the medical advisors were used only to "provide language and conclusions" in their reports that supported the denial of disability claims. If the reports could not be used to support denials, McSharry says, then he and the other doctors "were asked to delete and reword phrases so as not to compromise a denial."

The lawsuit further alleges that UnumProvident used nonmedical personnel called "claims specialists" and "appeals specialists" together with nurses to make benefits and medical-referral determinations rather than allow doctors to make those decisions.

In a statement, UnumProvident denies the allegations and says it "will vigorously defend the company. The company denies McSharry's contention that he was not allowed to do his job in an ethical fashion or that he was encouraged to engage in any illegal practice."

McSharry was employed by the company less than two years in a "nonmanagement role," says UnumProvident, and was one of over 60 fulltime physicians with the title of "medical director." Additionally, Dr. Leonard Morse, chair of the American Medical Association's Council on Ethical and Judicial Affairs and part-time UnumProvident medical consultant, says, "I have never experienced any corporate pressure on my decision making."

McSharry is asking for an unspecified amount in compensatory and punitive damages for his firing.

Alleged retaliation

The lawsuit chronicles McSharry's struggle as he "tried to work out his ethical dilemma with [UnumProvident's] practices and his role in them by walking a careful line, trying to follow [UnumProvident's] express rules while still rendering truthful reports."

According to McSharry's attorneys, when the doctor could no longer "maintain his own integrity," he informed the insurer that he would no longer participate in "illegal practices in the determination of disability benefits." McSharry says that after he began writing up his reports accurately he suffered "verbal and written write-ups and warnings" and was "subjected to constant criticism and ostracism." McSharry says his work was then handed off to others and he was fired in January 2002 for "disruptive behavior."

Stark contrast

McSharry's allegations are in stark contrast to July 11, 2002, testimony given before Congress by Dr. Robert Anfield, UnumProvident's current chief medical officer. According to the insurer, UnumProvident was asked to provide testimony because of its "best practices" disability expertise.

Anfield testified that UnumProvident looks "at every claimant as an individual, conducting a medical analysis of each case with our extensive in-house clinical resources and then — based on diagnosis and expected duration — develop an appropriate return-to-work plan tailored for the individual."

Do health insurers purposely delay and deny claims to maximize their profits?

McSharry, however, charges that it was UnumProvident's "policy to evaluate every medical condition of a claimant in isolation and to render a disability decision on the effects of each isolated condition rather than to consider restrictions of each condition in conjunction with other medical conditions." The result, he claims, was increased disability denials.

Additionally, the lawsuit alleges:

UnumProvident expected the medical advisors to render opinions on medical conditions outside his or her specialty rather than to refer the file to a specialist in the field. According to the lawsuit, the medical advisor had to document his training in that particular specialty "even where the support required falsification."

Medical advisors were not allowed to ask for further information on the claim or to suggest further tests. Their reviews were supposed to "stand on the record" and they were not supposed to help a claimant "perfect a claim."